New Client Enquiry For m

Thank you for interest in booking with Mullumbimby Psychology.

This is our new client enquiry form. Upon completion, you will be added to our waitlist or contacted if an appointment is available.

This form takes approximately 10 minutes to complete.

Click the next button to get started...

Date of Completion *

Enquirer Details

These are the details of person completing this form.

Title

MsMrMrsDr

First Name *

Last Name *

Preferred Name

Gender identity

Please specify

Date of Birth *

Email *

Please provide at least one phone number:

Phone *

Home

Work

What is your preferred method of communication? *

Phone CallSMSEmail

Who/what are you seeking services for? *If you are seeking more than one service - please complete a separate enquiry form for each service

Do you have any family members already attending our clinic? *

YesNoUnsure

Please provide names of family members:This information is used to determine conflicts of interest, if applicable.

First name of partner *

Last name of partner *

Preferred name

Partner's gender identity

Please specify

Date of birth *

First name of child *

Last name of child *

Preferred name

Child's gender identity

Please specify

Date of birth *

Name of school

Are both parents aware and do both parents consent to treatment *

YesNo

Please provide further information *(e.g. court order details)

Separated Parents:

Please carefully read the critical information summary at the following link: https://mullumbimbypsychology.com.au/separated-parents/

I have read the "Separated Parents and Service Provision to Children" document in full. I acknowledge and accept the scope and limitations of service provisions described.

First name *

Last name *

Preferred name

Relationship to me

Gender identity

Please specify

Date of birth *

Is this person aware that you are seeking treatment for them? *

Has this person consented to receiving psychological services? *

Please provide details of family members, including names, dates of birth and ages *

Are all family members aware of and consenting to treatment? Please provide details *

Referral Details

Do you have a current Mental Health Care Plan?

YesNo

Please see your GP for a long appointment (usually 20 minutes) to request a Mental Health Care Plan. Medicare rebates are only available for eligible GP referrals (e.g. Mental Health Care Plan, Enhanced Primary Care plan, Eating Disorder Plan).

Did your GP provide you with a copy of your Mental Health Care Plan? *

YesNo

Please upload your Mental Health Care Plan here:

Browse

Would you like us to request a copy of your Mental Health Care Plan on your behalf? *

YesNo

Name of Medical Centre which wrote the Mental Health Care Plan: *

Do you have an approved and current claim under Workers Compensation?

YesNo

Do you have a letter of approval for psychological counselling under your claim?

YesNo

Do you have an approved and current insurance claim?

YesNo

Do you have a letter of approval for psychological counselling under your claim?

YesNo

Please note that we do not provide services for Provider Managed plans but can provide services for self managed and plan managed clients.

Name of your employer?

Employee number(if available)

A referral is not required to see a psychologist. Rebates are available for most health funds with eligible membership.

Please provide details *

Payment Information

Our practice requires a deposit of 50% of the consult fee to be paid in order to secure your first appointment. If the intial booking is made over the phone, we will request card details to charge this deposit.

With your permission, your card details are stored in a secure, encrypted system. These card details are maintained on file for future use in the event that you incur cancellation fees or have Telehealth sessions (video/phone).

This deposit is then credited towards your first consult unless you do not attend or cancel within 48 hours' (2 business days) and we are unable to fill the appointment for the clinician.

Please find our cancellation policy as well as details of our fees at the following link: https://mullumbimbypsychology.com.au/fees/.

I acknowledge this practice policy regarding the deposit, card details storage and usage, and cancellation policy. *

Please tick if you have a health care card or pension card.

Needs and Preferences

Please outline the main reasons for seeking counselling *

Reports, Letters, and Assessments

Do you require a report, letter or assessment? *

YesNo

Please provide details of the required report, letter or assessment *

Please note that we are unable to provide some types of reports, letters, and assessments. If we are unable to provide a requested report, letter, or assessment, we will contact you to confirm if you’d like to still attend for treatment and to suggest alternative providers where possible.

Please note that production of reports, letters, or assessments which we are able to produce are not guaranteed and will be approved at discretion of the treating psychologist according to their clinical judgement and within the course of treatment, as per the Australian Psychological Society Code of Ethics.

These items often incur costs in addition to standard treatment charges, as they require additional hours of work outside of sessions. We will quote you for any reports, letters, or assessments in advance so you can decide if you wish to proceed.

Availability and Psychologist Preferences

Days and times available for sessions (please select all that apply)Please note have limited availability for psychologists on Saturdays

Please specify available timesMullumbimby Psychology operates within the hours of 9am-5pm on weekdays. Please note limited appointments are available out-of-hours and on weekends.

Preferred Psychologist/s

Leone Connable (4 month wait)Ella Wiseman (3 month wait)Giovanna Dalle Rive Carli (2 month wait)Facundo Cuesta (new client waitlist CLOSED until further notice)Amy Zurawic (6 - 8 month wait)Cristina Massia (4 month wait)Eric Van den Bossche (2 month wait)Carl Moore (3 month wait)Jaione Garcia Huarte (up to age 20 years old- 3 month wait)

For information about our psychologists, such as experience, working days, and psychologist status (i.e. Clinical, Registered, Provisional), please see the following link: https://mullumbimbypsychology.com.au/meet-the-team/.

Psychologists who are not listed above have closed their waitlist due to long wait times.

Are you open to the first available suitable psychologist?

YesNo

If you wish to see a specific psychologist, there is likely to be a longer wait.

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